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ABSTRACT: To study the accuracy of medical record scoring of the SLICC/ACR Damage Index (DI) for SLE.
Medical record DI (MDI) scoring of 60 SLE patients by one physician was compared with prospective direct DI (DDI) scoring a median of 2 y earlier. Agreement between DDI and MDI total and organ system scores was compared using Cohen's kappa, the degree of misclassification by MDI and the significance of differences between DDI and MDI scores.
The mean duration of SLE at DDI scoring was 5.2 y. The median/mean (SD) DDI and MDI total scores were 0/0.78 (1.38) and 0/0. 85 (1.44). Damage was present on DDI and MDI scoring in 36.7% (22/60) and 38.3% (23/60) of patients. Qualitative MDI and DDI total scores (damage present/absent) showed good agreement (kappa=0.61, 95% CI=0.40-0.82, 18.3% misclassification). Quantitative MDI and DDI total scores (degree of damage) showed moderate agreement (kappa=0. 47, 95% CI=0.28-0.66, 36.7% misclassification). 9 of 12 MDI organ system scores misclassified <10% of subjects. There was no statistically significant difference between DDI and MDI total or organ system scores.
MDI total scoring is a good qualitative and moderate quantitative reflection of SLE related damage. MDI organ system scores are more accurate than MDI total scores.
Lupus 02/2000; 9(5):358-62. · 2.34 Impact Factor
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ABSTRACT: The objective was to validate a Chinese translation of the Medical Outcomes Study Family and Marital Functioning Measures (FFM and MFM) in patients with systemic lupus erythematosus (SLE). Chinese-speaking SLE patients (n = 69) completed a self-administered questionnaire containing the FFM and MFM and assessing demographic and socio-economic status twice within a 2 week period. SLE activity, disease-related damage and quality of life were assessed using the BILAG, SLICC/ACR Damage Index and SF-36 Health Survey, respectively. Scale psychometric properties were assessed through factor analysis, Cronbach's alpha, quantifying test-retest differences and known-groups construct validity. Factor analysis identified 1 factor corresponding to the FFM and 2 factors corresponding to the MFM. Internal consistency for the FFM was excellent (alpha = 0.92) while that for the MFM was acceptable (alpha = 0.62). Mean (s.d.) test-retest differences were 0.06 (1.54) points for the FFM and 0.03 (2.08) points for the MFM. 11 and 10 of 13 a priori hypotheses relating the FFM and MFM, respectively, to demographic, disease and quality of life variables were confirmed, supporting the construct validity of these scales. The Chinese FFM and MFM are valid and reliable measures of family and marital functioning in Chinese-speaking SLE patients, with psychometric properties very similar to the source English version.
Lupus 02/2000; 9(9):702-7. · 2.34 Impact Factor
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ABSTRACT: We studied the reliability and validity of the Chinese Short-Form 36 Health Survey (SF-36) in a cross sectional study of patients with systemic lupus erythematosus (SLE). Sixty-nine consecutive subjects completed a questionnaire containing the Chinese SF-36 twice within 14 d. Disease activity and damage were assessed using the British Isles Lupus Activity Group (BILAG) and SLICC/ACR Damage Index (DI) scales, respectively. Internal consistency was assessed using Cronbach's alpha, reliability using Spearman's correlation and repeatability coefficients, and relationships between SF-36, BILAG and DI scores using Spearman's correlation. The Chinese SF-36 showed high internal consistency (alpha = 0.72-0.91) and good reliability, with correlations exceeding 0.70 for 7 scales and mean scale score differences of < 2 points for 6 scales. SF-36 scores correlated weakly with BILAG scores (-0.27 to -0.41) and DI scores (-0.24 to -0.35), and subjects' mean SF-36 scores were 6-24 points lower than the general population, supporting construct validity of the SP-36. These data suggest that the Chinese SF-36 is a reliable and valid measure of quality of life in patients with SLE.
Lupus 02/2000; 9(9):708-12. · 2.34 Impact Factor
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ABSTRACT: To assess the internal consistency, reliability, and construct validity of the Rheumatology Attitudes Index (RAI) and its subscales in a cohort of Asian patients with systemic lupus erythematosus (SLE).
English speaking ethnic Chinese, Malay, or Indian patients with SLE (n = 120) seen at a rheumatology unit completed a questionnaire containing the RAI twice within a 2 week period. Lupus activity was assessed using the British Isles Lupus Activity Group (BILAG) score, disease related damage using the Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) damage index, and quality of life using the Medical Outcome Survey Short Form 36 Health Survey (SF-36). Factor analysis and Cronbach's alpha were used to study the psychometric properties of the RAI. The magnitude of test-retest differences was assessed using the method of Bland and Altman. Relationships between the RAI, its helplessness (HS) and internality (IS) subscales, and BILAG, SLICC/ACR damage index and SF-36 scores were studied using Spearman's rank correlation.
Factor analysis (n = 105) identified 2 factors corresponding to the HS and IS subscales of the RAI. All scales showed acceptable internal consistency, with Cronbach's alpha of 0.64 for the HS, 0.77 for the IS, and 0.74 for the RAI. Mean (SD) test-retest differences were 0.85 (3.96) points for the HS (n = 86), 0.81 (4.44) points for the IS (n = 85), and 1.46 (7.88) points for the RAI (n = 74). Six of 10 hypotheses relating the RAI and HS to demographic, disease, and quality of life variables were confirmed, supporting the construct validity of these scales.
The RAI and its helplessness subscale are valid and reliable measures of learned helplessness in a multiethnic cohort of Asian patients with SLE in Singapore.
The Journal of Rheumatology 08/1999; 26(7):1512-7. · 3.69 Impact Factor
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ABSTRACT: To validate the Medical Outcomes Study Family and Marital Functioning Measures (FMM and MFM) in a multi-ethnic, urban Asian population in Singapore.
English speaking Chinese, Malay or Indian SLE patients (n=120) completed a self-administered questionnaire containing the FFM and MFM at baseline, after 2 weeks and after 6 months. Lupus activity, disease-related damage and quality of life were assessed using the British Isles Lupus Assessment Group (BILAG), Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index and SF-36 Health Survey respectively. Scale psychometric properties were assessed through factor analysis, Cronbach's alpha, quantifying test-retest differences and known-groups construct validity.
Factor analysis of scores obtained at baseline and after 6 months identified 3 factors corresponding to the FFM (1 factor) and the MFM (2 factors). Both scales showed acceptable internal consistency, with Cronbach's alpha of 0.95 for the FFM and 0.70 for the MFM. Mean (s.d.) test-retest differences were -0.31 (3.82) points for the FFM and -0.70 (4.26) points for the MFM. Eleven out of 13 a priori hypotheses relating both the FFM and MFM to demographic, disease and quality of life variables were confirmed, supporting the construct validity of these scales.
The FFM and MFM are valid and reliable measures of family and marital functioning in a multi-ethnic cohort of Asian SLE patients in Singapore.
Lupus 02/1999; 8(7):514-20. · 2.34 Impact Factor
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ABSTRACT: To assess the reliability and construct validity of the Medical Outcomes Study Short Form 36 Health Survey (SF-36) in a multiracial cohort of Asian patients with lupus in Singapore.
A cross sectional study was performed on 118 English speaking patients with lupus attending a specialist rheumatology unit between March and August 1996. Patients completed a questionnaire containing the UK standard version of the SF-36 twice within a 14 day period. All patients were assessed for disease activity using the British Isles Lupus Assessment Group score (BILAG), and for disease related damage using the Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) damage index (DI). Relationships between SF-36, BILAG, and DI scores were studied using Spearman's rank correlation. Internal consistency of the SF-36 was assessed using Cronbach's alpha, and stability using the repeatability coefficient of Bland and Altman.
SF-36 subscales showed high internal consistency, with Cronbach's alpha coefficient ranging from 0.84 to 0.94. Test-retest reliability was acceptable, with Spearman's rank correlation >0.70 for all subscales except role-physical, and mean differences in test scores of <2 points for 5 of 8 subscales. SF-36 subscale scores were weakly correlated with BILAG scores (Spearman's p -0.37 to 0.15) and SLICC/ACR DI scores (Spearman's p -0.25 to 0.23), suggesting divergent construct validity of the SF-36.
These data suggest the SF-36 is a reliable and valid measure of the quality of life of patients with lupus in Singapore.
The Journal of Rheumatology 02/1999; 26(1):97-102. · 3.69 Impact Factor
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ABSTRACT: To describe trends in systemic lupus erythematosus (SLE) incidence and mortality over the past 4 decades.
Using the Rochester Epidemiology Project resources, medical records were screened to identify all Rochester, Minnesota residents with any SLE-associated diagnoses, discoid lupus, positivity for antinuclear antibodies, and/or false-positive syphilis test results determined between January 1, 1980 and December 31, 1992. Medical records were then reviewed using a pretested data collection form in order to identify cases of SLE according to the American College of Rheumatology 1982 revised criteria for SLE. Drug-induced cases were excluded. All identified SLE patients were followed up until death, migration from the county, or October 1, 1997. These data were combined with similar data from the same community obtained between 1950 and 1979, and trends in the SLE incidence and mortality over time were calculated.
Of the 430 medical records reviewed, 48 newly diagnosed cases of SLE (42 women and 6 men) were identified between 1980 and 1992. The average incidence rate (age- and sex-adjusted to the 1970 US white population) was 5.56 per 100,000 (95% confidence interval [95% CI] 3.93-7.19), compared with an incidence of 1.51 (95% CI 0.85-2.17) in the 1950-1979 cohort. The age- and sex-adjusted prevalence rate as of January 1, 1993 was approximately 1.22 per 1,000 (95% CI 0.97-1.47). Survival among SLE patients was significantly worse than in the general population (P = 0.017 compared with the 1980-1992 cohort, and P < 0.0001 compared with the 1950-1979 cohort, by log-rank test). Cox proportional hazards modeling demonstrated a statistically significant improvement in the survival rate over time (P = 0.035).
Over the past 4 decades, the incidence of SLE has nearly tripled, and there has been a statistically significant improvement in survival. These findings are likely due to a combination of improved recognition of mild disease and better approaches to therapy.
Arthritis & Rheumatism 02/1999; 42(1):46-50. · 7.87 Impact Factor
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J Thumboo,
K Y Fong,
H H Chng,
E T Koh,
H P Chia,
K H Leong,
W H Koh,
H S Howe,
K P Leong,
M H Wong, [......],
P Chai,
L H Goh,
T J Goon,
T C Lau,
W S Lim,
W Y Pek,
K L Tong,
W L Yang,
P H Feng,
M L Boey
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ABSTRACT: To determine the effects of ethnicity on disease manifestations in Oriental patients with systemic lupus erythematosus (SLE) and to describe the risk of developing renal or central nervous system (CNS) involvement with time.
A retrospective study of 472 patients with SLE seen at the only Rheumatology Unit in Singapore. The effect of ethnicity on selected disease manifestations at diagnosis was assessed after adjusting for demographic variables using multiple logistic regression. The probability of developing selected disease manifestations with time was determined using the Kaplan-Meier product limit method.
At diagnosis, Malays had a higher risk of renal or CNS involvement than Chinese (OR 2.26, 95% CI 1.21 to 4.21, and OR 3.07, 95% CI 1.01 to 9.34, respectively), and Indians a lower risk of malar rash and a higher risk of oral ulcers than Chinese (OR 0.30, 95% CI 0.13 to 0.68, and OR 2.90, 95% CI 1.45 to 7.34, respectively). The prevalence of renal or CNS involvement in the entire cohort increased with time, reaching 75.6% (95% CI 66.1% to 85.0%) and 16.7% (95% CI 11.7% to 21.6%), respectively, after 18 years of disease.
Ethnicity influenced disease manifestations at diagnosis in this cohort of Oriental patients with SLE. Renal or CNS involvement developed in previously unaffected patients up to 18 years after diagnosis, highlighting the need for continued vigilance in patients with lupus.
The Journal of Rheumatology 08/1998; 25(7):1299-304. · 3.69 Impact Factor
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J Thumboo,
K Y Fong,
H P Chia,
H H Chng,
E T Koh,
K H Leong,
W H Koh,
H S Howe,
K P Leong,
M L Boey,
P H Feng
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ABSTRACT: We identified clinical predictors of lupus nephritis presenting more than 6 months after the diagnosis of lupus in a cohort of 335 lupus patients. Almost 24% (80/335) of patients developed nephritis more than 6 months after the diagnosis of lupus. Using a Cox proportional hazards model, we found hypertension, thrombocytopaenia and leukopaenia to be associated with lupus nephritis presenting more than 6 months after diagnosis, with adjusted relative risks of 2.5 (95% CI 1.3 to 4.7), 4.3 (95% CI 1.7 to 10.8) and 3.2 (95% CI 1.7 to 6.2) respectively. In this cohort, hypertension, thrombocytopaenia and leukopaenia were associated with lupus nephritis presenting more than 6 months after the diagnosis of lupus.
Annals of the Academy of Medicine, Singapore 01/1998; 27(1):16-20. · 1.25 Impact Factor
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ABSTRACT: To determine the clinical features of psoriatic arthritis (PsA) in a multiethnic Oriental population and to study the effect of ethnicity on disease patterns.
A retrospective study of 80 patients with PsA seen at either a rheumatology or dermatology referral center. Patients and case records were reviewed and data abstracted according to a standard protocol. Eighty consecutive patients with psoriasis without PsA seen at the dermatology center were recruited as controls.
Asymmetric polyarthritis developing in the 4th decade with an equal male to female ratio was the commonest pattern of arthritis among Chinese, Indians, and Malays. Clinically apparent lumbar spondylitis was significantly more common in Indians than Chinese (10/11 vs 11/20, respectively; p = 0.046), although the prevalence of lumbar spondylitis was similar in all ethnic groups. Eighty-nine percent of subjects required nonsteroidal antiinflammatory drugs and 51% required disease modifying antirheumatic drugs at some time for control of joint disease. PsA was significantly more common among Indians compared to the ethnic distribution of the Singapore population (p < 0.000001). Multiple logistic regression identified Indian ethnicity as a risk factor for the development of PsA (OR 2.39, 95% confidence interval 1.02 to 5.60).
The commonest pattern of PsA in all ethnic groups was asymmetric polyarthritis. Ethnicity affected the development and presentation of PsA in our series: Indians with psoriasis had double the risk of developing PsA compared to Chinese with psoriasis, and lumbar spondylitis when present in Chinese subjects was asymptomatic in 45%, being detectable only on radiological examination.
The Journal of Rheumatology 10/1997; 24(10):1949-53. · 3.69 Impact Factor
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ABSTRACT: The objective of this study was to determine if the Short Form 36 (SF-36) Health Survey Questionnaire measures differences in quality of life between lupus patients and healthy controls in Singapore. A cross-sectional pilot study was conducted on consecutive English-speaking, female Chinese lupus patients seen at a Rheumatology unit. Healthy volunteers were recruited as controls during the same time period. All subjects completed the United Kingdom version of the SF-36. Lupus disease activity was assessed using the British Isles Lupus Assessment Group (BILAG) index and converted to a global score. Lupus-related damage was measured using the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SLICC/ACRDI). The main outcomes measured were the mean SF-36 scale scores for lupus patients and healthy controls. Thirty-six lupus patients and 76 controls were included in the study. All subjects were English-speaking, Chinese female between 21 and 53 years of age. The mean age of patients and controls was 31.9 and 29.0 years respectively. Lupus patients had lower mean scale scores than controls for physical functioning (73.0 versus 89.7, P < 0.0027), bodily pain (71.0 versus 81.4, P < 0.027), physical role functioning (55.7 versus 89.5, P < 0.0001) and general health (47.4 versus 51.8, P < 0.05). Mean scale scores for vitality, social and emotional role function and mental health were similar in both groups. Ten patients had active disease (BILAG global scores of 3 to 14) and 13 patients had lupus-related damage (Damage Index scores of 1 to 7). These preliminary data suggest that the SF-36 Health Survey may be able to measure differences in quality of life between lupus patients and healthy controls in Singapore.
Annals of the Academy of Medicine, Singapore 05/1997; 26(3):282-4. · 1.25 Impact Factor
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K Y Fong, J Thumboo,
E T Koh,
H H Chng,
K H Leong,
W H Koh,
H S Howe,
K P Leong,
B Lim,
D R Koh,
S C Ng,
P H Feng,
M L Boey
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ABSTRACT: We studied the initial manifestations and late features in our lupus patients. The clinical data of patients fulfilling the American College of Rheumatology criteria for systemic lupus erythematosus (SLE) were entered prospectively for newly diagnosed patients and cumulatively for those with at least 10 years of disease duration. Ninety-seven Group A (newly diagnosed; 86 females and 11 males; mean age 31 years; 83 Chinese, 11 Malays, and 3 Indians) and 58 Group B (more than 10 years disease duration; 56 females and 2 males; mean age 41 years; 50 Chinese, 5 Malays, and 3 Indians) lupus patients were studied. The commonest clinical features in Group A were: haematological (73%), arthritis (57%), malar rash (43%), renal disorder (31%) and photosensitivity (30%). Group B patients had haematological (78%), malar rash (73%), arthritis (69%), renal disorder (59%) and photosensitivity (33%). Renal disorder was significantly increased over the years (P < 0.001). Hypertension was present in 18% (Group A) and 59% (Group B) (P < 0.00001), diabetes mellitus in 5% (Group A) and 10% (Group B) (P = ns), atherosclerosis in 2% (Group A) and 7% (Group B) (P = ns). Cataract formation was not present in Group A patients but was present in 10% of Group B patients. Renal disorders and morbidity factors like hypertension and cataracts increased significantly over the years. Optimum treatment of lupus patients should therefore include close attention to these factors.
Annals of the Academy of Medicine, Singapore 05/1997; 26(3):278-81. · 1.25 Impact Factor
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ABSTRACT: A retrospective review of 50 oriental patients with rheumatoid arthritis treated with weekly oral methotrexate showed adverse events in 15 (30%) patients with 19 occurrences (38%) of leucopaenia (4%), pancytopaenia (2%), gastrointestinal symptoms (18%), hepatic transaminase elevation (6%), rash (2%) and infections (6%). The median duration of treatment with methotrexate was 11 months (range 1 to 105 months). Pancytopaenia occurred in 1 patient with renal failure. All adverse events resolved with cessation of therapy and on several occasions, despite continued therapy. Methotrexate was discontinued permanently in 2 and temporarily in 7 patients as a result of adverse events. No recurrence of adverse events was noted on restarting methotrexate therapy in patients with non life-threatening adverse events. No increase in adverse events was noted in 14 patients treated with a combination of methotrexate and anti-malarial therapy. We conclude that methotrexate was well tolerated by the Oriental patients with rheumatoid arthritis in our study and could be safely restarted in those patients with non life-threatening adverse events.
Annals of the Academy of Medicine, Singapore 04/1997; 26(2):205-9. · 1.25 Impact Factor
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ABSTRACT: We reviewed the case records of 10 Oriental patients with systemic lupus erythematosus (SLE) who developed pulmonary haemorrhage (PH) between 1987 and 1996 to determine their clinical presentation and outcome. All the patients had clinical evidence of PH including a sudden onset of dyspnoea, tachycardia, fall in haemoglobin (at least 1.5 gm%) and bilateral diffuse alveolar infiltrates on chest radiographs. At the time of PH, nine patients had a disease duration of 2 years or less and all the patients had clinical and/or laboratory evidence of active lupus disease. Fever and lung crepitations were present in 90% of patients while haemoptysis and chest pain occurred in only three and two patients, respectively. All the patients were treated with high dose intravenous corticosteroids and in addition seven had a combination of pulse methylprednisolone and cyclophosphamide, and four had received plasmapheresis. Four patients died as a result of PH. One patient died of pneumonia three years after recovering from PH while the remaining five had no recurrence of PH after a median follow-up of 22 months. Our study suggests that PH in Oriental lupus patients often occurs early in the disease, rarely presents with haemoptysis and has a high mortality despite aggressive immunosuppressive therapy.
Lupus 02/1997; 6(9):713-6. · 2.34 Impact Factor
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ABSTRACT: Computerized health-related quality of life (HRQoL) administration may facilitate clinical trials incorporating HRQoL assessment in rheumatology patients by reducing sample size requirements. We tested this hypothesis in a pilot randomized controlled trial.
Chinese-speaking adult rheumatology outpatients were randomized to computerized (PC) or interviewer (IA) administration of the EQ-5D (utility & VAS), Health Utilities Index (HUI2 & HUI3) and Family Functioning Measure (FFM). We compared measurement variability (i.e., variance) between PC and IA for each instrument before (Levene's test) and after adjusting for the effects of age, gender and education (multivariable modeling) and computed the variance ratio (VR) for PC over IA.
In 138 patients (mean age: 48), the mean (SD) time for administration was similar for PC (n = 67) and IA (n = 71) at 17.7 (7.94) versus 17.3 minutes (7.49), respectively. More subjects expressed a preference for PC (n = 21) over IA (n = 13). Mean HRQoL scores were not significantly different for PC versus IA except for higher VAS scores with IA (difference -7.7, 95% CI -14.0 to 1.3, p = 0.018). Variances and adjusted VR were smaller with PC for the EQ-5D (adjusted VR 0.34, 95% CI 0.18 to 0.65), HUI3 (0.49, 0.27 to 0.89) and FFM (0.95, 0.61 to 1.46), but larger for the HUI2 (1.30, 0.67 to 2.55) and VAS (1.05, 0.55 to 2.00).
The reduced variability in 3 of 5 instruments and good acceptance of computerized HRQoL assessment, if confirmed in larger studies, may lead to smaller sample size requirements, with potential reductions in cost and recruitment time for clinical trials and cohort studies.
Clinical and experimental rheumatology 25(4):577-83. · 2.15 Impact Factor
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ABSTRACT: Cogan's syndrome (CS) is a rare multisystemic disease characterized by vestibuloauditory dysfunction, inflammatory eye disease and vasculitis. Aortic aneurysms due to aortitis are under-recognized in CS, and are potentially fatal, with two of eight reported cases dying from aneurysm/arterial rupture. The presence of aneurysms was not recognized antemortem in both cases, highlighting the importance of early detection to prevent this potentially fatal outcome. We report a 17-year-old Chinese male with recurrent carotid and aortic aneurysms, bilateral sensorineural hearing loss, and recurrent scleritis who was initially thought to have Marfan syndrome. The diagnosis of CS was made 4.5 years after initial presentation, during which time recurrent aneurysms due to active aortitis (with aneurysmal rupture on one occasion) necessitated four surgical procedures. Treatment with methotrexate and corticosteroids resulted in no recurrence of aneurysms over 2 years of follow-up. This case illustrates (i) the challenges in diagnosing CS when various manifestations occur separately over a relatively long time period, (ii) that detection of aortic aneurysms in young patients, especially if recurrent, should prompt investigations for vasculitis/aortitis to prevent potentially fatal aneurysm rupture, and (iii) that methotrexate and high-dose corticosteroids may be effective in preventing development of further aneurysms in CS patients.
Scandinavian Journal of Rheumatology 36(1):71-3. · 2.47 Impact Factor
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ABSTRACT: BACKGROUND
To characterize ease in discussing death (EID) and its influence on health valuation in a multi-ethnic Asian population and to determine the acceptability of various descriptors of death and "pits"/"all-worst" in health valuation.
METHODS
In-depth interviews (English or mother-tongue) among adult Chinese, Malay and Indian Singaporeans selected to represent both genders and a wide range of ages/educational levels. Subjects rated using 0–10 visual analogue scales (VAS): (1) EID, (2) acceptability of 8 descriptors for death, and (3) appropriateness of "pits" and "all-worst" as descriptors for the worst possible health state. Subjects also valued 3 health states using VAS followed by time trade-off (TTO). The influence of sociocultural variables on EID and these descriptors was studied using univariable analyses and multiple linear regression (MLR). The influence of EID on VAS/TTO utilities with adjustment for sociocultural variables was assessed using MLR.
RESULTS
Subjects (n = 63, 35% Chinese, 32% Malay, median age 44 years) were generally comfortable with discussing death (median EID: 8.0). Only education significantly influenced EID (p = 0.045). EID correlated weakly with VAS/TTO scores (range: VAS: -0.23 to 0.07; TTO: -0.14 to 0.11). All subjects felt "passed away", "departed" and "deceased" were most acceptable (median acceptability: 8.0) while "sudden death" and "immediate death" were least acceptable (median acceptability: 5.0). Subjects clearly preferred "all-worst" to "pits" (63% vs. 19%, p < 0.001).
CONCLUSION
Singaporeans were generally comfortable with discussing death and had clear preferences for several descriptors of death and for "all-worst". EID is unlikely to influence health preference measurement in health valuation studies.
